Clinical Policy: Outpatient Cardiac Rehabilitation Form

CENTENE® Corporation

Clinical Policy: Outpatient Cardiac Rehabilitation Reference Number: CP.MP.176 Date of Last Revision: 02/25

Coding Implications Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description The American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation define cardiac rehabilitation for coronary heart disease as “coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality.”¹² This policy describes the medical necessity guidelines for conventional and intensive outpatient cardiac rehabilitation programs.

Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that initiation of

medically supervised phase II outpatient cardiac rehabilitation is medically necessary when
meeting all the following:
A.  Indications, one of the following:
    1.  Stable angina pectoris within last 12 months⁶;
    2.  Percutaneous coronary intervention within last 12 months⁶;
    3.  Myocardial infarction within last 12 months⁶;
    4.  Coronary artery bypass graft (CABG) within last 12 months⁶;
    5.  Coronary artery disease (CAD) within last six months⁶;
    6.  New York Heart Association (NYHA), Class II, III, or IV and on a stable medication
        regimen³,⁶;
    7.  Heart or heart-lung transplantation within last six months, or within six months of
        newly gained ability to participate in rehabilitation regimen⁶;
    8.  Cardiac valve surgery within last six months⁶;
    9.  Peripheral artery disease within last 12 months;
    10. History of sustained ventricular tachycardia or fibrillation, or survivors of sudden
        cardiac death;
    11. Surgical septal myectomy via thoracotomy within last 12 months.
B.  Therapy program, all of the following:
    1.  Physician-prescribed exercise during each session;
    2.  Electrocardiogram monitoring;
C.  Request is for ≤ 36 visits over a period of ≤ nine months¹⁶;
D.  None of the following contraindications:
    1.  Unstable angina;
    2.  Orthostatic BP drop of >20 mmHg with symptoms;
    3.  Symptomatic severe aortic stenosis (aortic valve area <1.0 cm²);
    4.  Uncontrolled atrial or ventricular arrhythmias with hemodynamic compromise;
    5.  Decompensated heart failure;
    6.  Active pericarditis or myocarditis;
    7.  Active pulmonary embolism, pulmonary infarction or deep vein thrombosis;
    8.  Acute thrombophlebitis⁴¹;
    9.  Acute systemic illness or fever;
    10. Unstable or life-threatening noncardiovascular conditions such as active infection,
        uncontrolled diabetes, end-stage cancer, or unstable psychological issues;
    11. Severe orthopedic conditions that would prohibit exercise;
    12. Active endocarditis
    13. Acute aortic dissection.

II. It is the policy of health plans affiliated with Centene Corporation that continuation of

medically supervised phase II outpatient cardiac rehabilitation is medically necessary when
meeting all of the following:
A.  Progressive therapy program, all the following:
    1.  Physician-prescribed exercise during each session;
    2.  Electrocardiogram monitoring;
B.  Partial progress made in meeting treatment goals, all of the following:
    1.  Reduction in intensity and frequency of symptoms or findings;
    2.  Improvement in function and reduction in limitations;
    3.  Documented patient adherence to home exercise program;
C.  Request is for ≤ 36 visits, including those initially approved. Requests for additional
    visits will be reviewed by a medical director.

III. It is the policy of health plans affiliated with Centene Corporation that phase III or IV

cardiac rehab programs are not medically necessary, as they are primarily educational or
training programs.

IV. It is the policy of health plans affiliated with Centene Corporation that there is not sufficient

evidence that intensive cardiac rehabilitation programs achieve superior outcomes when
compared to conventional cardiac rehabilitation programs.

Background Cardiac rehabilitation (CR) programs should include comprehensive long-term services involving medical evaluation/baseline patient assessment, exercise training and physical activity counseling, coronary risk factor reduction/secondary prevention, including nutritional counseling and weight management, psychosocial support, and education regarding diet, medications, and exercise tolerance.³ An updated Cochrane systematic review and meta-analyses demonstrate important benefits of cardiac rehabilitation (CR) for coronary heart disease (CHD) and heart failure (HF), such as reduction in mortality, heart attacks and hospital readmissions, as well as improvements in exercise duration and health related quality of life.²,³⁴ Although the reporting of methods has improved in recent trials, well designed, adequately reported random controlled trials of CR in people with CHD more representative of usual clinical practice are still needed.²

Cardiac rehabilitation is recommended for patients with stable New York Heart Association (NYHA) class II to III HF with benefits seen as early as three weeks following training.²⁵ The Centers for Medicare and Medicaid Services (CMS) further describes stable chronic heart failure as “left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks.

Stable patients are defined as patients who have not had recent (≤ six weeks) or planned (≤ six months) major cardiovascular hospitalizations or procedures”⁶.

Phase II outpatient CR programs provide electrocardiogram-monitored, supervised exercise programs tailored to the needs of the patient, usually two to three times weekly for eight to 12 weeks or longer. Goals include reducing coronary risk factors, identifying and managing psychosocial problems that affect patients with cardiac disease, and teaching safe and effective exercise prescribed by a physician or other qualified practitioner.³

Intensive cardiac rehabilitation According to the Centers for Medicare and Medicaid Services, “intensive cardiac rehabilitation (ICR) refers to a physician-supervised program that furnishes cardiac rehabilitation services more frequently and often in a more rigorous manner” than conventional programs. In order to qualify, ICR programs must demonstrate in peer-reviewed literature that they achieved at least one of the following outcomes: (1) positively affected the progression of coronary heart disease; (2) reduced the need for coronary bypass surgery; and (3) reduced the need for percutaneous coronary interventions.⁵ Several intensive cardiac rehabilitation programs have been established including, but not limited to the Pritikin Program, the Ornish Program for Reversing Heart Disease, and the Benson-Henry Institute Cardiac Wellness Program. The Pritikin, Ornish, and Benson-Henry Institute programs are licensed, commercial products with varying program components, which include exercise, nutrition counseling, stress management and small group support that often includes one to two-year follow up.⁵,¹¹,³⁵,³⁶,³⁷

A small randomized controlled trial of 93 patients with coronary artery disease compared patients assigned to ICR (the Ornish program) with those assigned to conventional CR. The report demonstrated significant improvements in dietary habits, weight and body mass index (BMI) as compared with the conventional group. However, there was no significant reduction in the carotid intima-media thickness of the carotid artery in the Ornish group or the conventional CR group.¹

An additional study of 314 patients with high-risk cardiovascular disease (CVD) were assessed to evaluate ICR and standard CR programs with 101 patients enrolled in the ICR program and 213 patients enrolled in the standard CR program. Findings demonstrated significant improvements in cardiometabolic outcomes for those in the ICR program and improvement in dietary habits, psychosocial well-being, and reduced incidence of long-term major adverse cardiac events. Despite encouraging results, further research is needed to evaluate various components associated with ICR safety, effectiveness, feasibility and long-term benefits in CVD patients. The authors caution that further generalizations based on their findings “requires caution associated with sample size, one year period of follow-up, and lack of no control group, which may be considered as a limitation”.³⁵

In a study conducted by Medicare from 2000 to 2008 examining outcomes of 580 patients enrolled in two intense lifestyle modification programs (The Dr. Dean Ornish Program for Reversing Heart Disease [Ornish] and the Cardiac Wellness Program of the Benson-Henry Mind/Body Medical Institute [MBMI]), findings demonstrated statistically significant reductions in both programs in body weight, systolic and diastolic blood pressure, and LDL cholesterol. The changes were sustained in participants who remained in each program for two years. Expressed limitations of the study include the observational pre-post design and the absence of a control group. Additionally, the authors note that additional research is needed to determine the relative effectiveness and cost-effectiveness of traditional cardiac rehabilitation versus no cardiac rehabilitation relative to patient outcomes.³⁷

A retrospective analysis was conducted to determine the benefits of the first Pritikin outpatient ICR program. The retrospective analysis followed patients referred to ICR or conventional cardiac rehabilitation between 2013 through 2019. The ICR program consisted of education sessions in addition to monitored exercise sessions that comprise the conventional CR. A total of 1,963 patients enrolled in the program with 1,141 patients completing the program. The Pritikin outpatient ICR program demonstrated improvements in several cardiovascular health indices. The authors note that critical next steps to assess long-term health outcomes following ICR, including cardiac events and mortality.¹¹

Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

Codes that support coverage criteria

Codes that do not support coverage criteria

Codes that do not support coverage criteria

Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists,